Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation
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RESEARCH ARTICLE
Open Access
Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation Heather A. Vallier1*, Timothy A. Moore1,2, John J. Como3, Patricia A. Wilczewski3, Michael P. Steinmetz4, Karl G. Wagner5, Charles E. Smith5, Xiao-Feng Wang1 and Andrea J. Dolenc1
Abstract Background: Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time. Methods: Three hundred thirty-five patients with mean age 39.2 years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (n = 173), pelvic ring (n = 71), acetabulum (n = 57), and/or spine (n = 79) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36 h if lactate 2, were considered severe. Fracture characteristics, associated injuries, medical co-morbidities, and the timing and techniques of provisional treatment and surgical procedures were documented.
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In cases of persistent acidosis, damage control was recommended if fractures were amenable to this. Ongoing clinical and laboratory reassessment was performed, and a safe time for definitive fixation was determined by the attending trauma surgeon. In the event of ongoing active bleeding secondary to fracture, with failure to respond to conventional methods including splinting, transfusion, and angiography, the general trauma surgeon could recommend fixation or amputation as a life saving measure. For patients with two or more of the fractures of interest, the orthopedic trauma surgeon would propose a plan for sequence of fixation. The general trauma surgeon would review this plan and propose incorporation of any other procedures warranted prior to fracture care or within the same surgical setting. The trauma surgeon, in conjunction with the orthopedic trauma and anesthesia teams, would reassess the patient during the first of multiple procedures and sequentially thereafter to determine the safety of continuing surgery. Worsening acidosis would be considered an indication to delay additional procedures. Notably, some patients would have open extremity fractures for which a minimum of urgent debridement and irrigation followed by splinting and/or external fixation was anticipated in the initial surgical setting. Standard inpatient protocols for antibiotic usage, DVT prophylaxis, and nutrition were in place and unchanged throughout the study period.
EAC protocol
Inclusion criteria were patients with mechanically unstable fractures of the proximal or diaphyseal femur, pelvic ring, acetabulum, and/or spine requiring fixation. All patients had a presenting ISS ≥16 and at least one of the following: injury to one or more other body systems, hemodynamic instability on p
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